Lecture 25

1. Be able to demonstrate the proper technique for examination of the breasts.
Not on exam

2. Given the clinical examination of any patient presenting with a breast mass, be able to:
a. Identify the features that suggest that the mass is "probably benign" or "probably malignant"
Probably benign – a lesion that is smooth, rounded or lobulated, mobile, discrete (well-circumscribed border), soft to rubbery firm consistency
DDx – fibroadenoma, cyst, intraductal papilloma, cystoscarcoma phyllodes (benign/malignant), sebaceous cyst, lipoma, metastatic cancer, primary breast cancer.
Probably malignant – a lesion that is irregular in shape; immobile with respect to adjacent breast tissue, skin, or chest wall; ill-defined margins; and firm to rock hard, +/-- skin changes.
DDx – cancer, fibrocystic changes, infection, fat necrosis.

b. Describe the appropriate evaluation to disclose the definitive diagnosis
(So for some reason I can't imbed an image, so I'm just going to email you the flowchart I made based on notes/slides)

c. Describe the clinical presentation of "fat necrosis" of the breast.
Can mimic breast cancer on physical exam and mammogram (see above).
History of trauma/prior surgery, remembered in 50%
Superficial mass, associated with skin retraction
Stellate mass w/ calcifications on mammography
Often requires surgical biopsy to get the diagnosis

3. Given any patient with a normal clinical examination found to have a suspicious lesion on screening mammography, be able to:
a. Choose the best of the three options for management and
Early mammographic follow up and physical exam in 4-6 months
• ACR category 3 – probably benign
• If stereotactic technique has shown a negative result
Needle localized surgical excisional breast biopsy
• Suspicious abnormality, or highly suggestive of malignancy
Stereotactic or sonographic guided core needle biopsy or FNA – core needle biopsy is more commonly done that FNA because FNA has more inadequate sampling and requires an experienced cytopathologist. Rationale for either is to reduce surgeries for benign findings. Most commonly done.
• Indications for stereotactic breast biopsy – Low to intermediate suspicion lesion
• Sample other abnormalities when patient is having surgical biopsy for a more suspicious lesion
• Patient is not a candidate for breast conservation if cancer diagnosed
• Significant co-morbid medical conditions that make surgery undesirable
• Lesion identified in one mammographic view only

b. List the indications for referral to a surgeon.
For ACR categories 4 and 5 (Mammography – BIRADS – Nomenclature)
4 – Suspicious abnormality; biopsy should be considered
5 – Highly suggestive of malignancy; appropriate action should be taken
*Note that ACR 0 = assessment is incomplete, and it requires additional imaging studies*

4. Given any clinical examination of a patient with a nipple discharge, be able to:
a. Identify which symptoms suggest an increased likelihood of cancer
Serous, serosanguinous, sanguinous or water in nature
Associated with a mass
Unilateral
Uniductal
Spontaneous
Associated with abnormal cytology or abnormal mammogram
Occurring in a patient >50 years old
b. Recognize when the likely diagnosis is fibrocystic disease
Multi-ductal
Multi-colored
Bilateral
Usually elicited with manual comrpession
c. The differential diagnosis of galactorrhea
Oral contraceptives
Thyroid disease
Chest wall trauma or stimulation
Pituitary adenomas
Medications – phenothiazines, reserpine, methyldopa
d. Describe the appropriate evaluation.
P/E – characterize color, location, multiple/single ducts, amount, ease of flow.
Spontaneous non-lactational galactorrhea – check prolactin and thyroid function tests
Dark or bloody discharges – hemoccult tested. Cytologic examination. Biopsy (whether cytology is positive/negative)
Manage worrisome discharges by cannulation and excision of the involved duct and its arborization. Do ductogram first only if it will influence the decision for surgical excision (may help to localize better the intraductal lesion to facilitate excision).

5. Given the clinical presentation of any patient with breast pain, be able to:
a. List the six most common etiologies
Diffuse fibrocystic changes – waxes and wanes in severity related to hormonal cycling. More severe if patient, especially a postmenopausal patient, is on hormone replacement therapy; and regress if hormone is stopped.
Sudden enlargement of a gross cyst – cyst is found on P/E, which should be aspirated
Breast infection – has other signs of inflammation
Physiologic hormonal cycling or exogenous hormone therapy
Costochondritis
Cancer – consider especially in older women not on hormone replacement therapy. May have other ssx of breast cancer
b. Describe the appropriate further evaluation
Physical examination – rule out mass lesion or inflammatory condition
Mammography – women >40 + women 30-40 depending on history, P/E, and prior available mammograms
c. Diagnose which of the above etiologies is present
See above

6. Given the clinical presentation of any patient with an inflammatory condition of the breast, be able to:
a. List the six most common etiologies and
Mastitis – inflammation of the mammary gland
Abscess – may have a fluctuant (moveable, compressible) area, which should be aspirated to confirm abscess and get material for culture
Recurring subareolar abscess – spontaneous drainage of pus from around the nipple areolar complex
Skin infections such as folliculitis or an infected sebaceous cyst
Superficial thrombophlebitis
Cancer – consider in patient w/ erythematous, edematous, firm breast w/o fever or other systemic signs of infection, and who fail to respond to antibiotic therapy

b. Recognize which is most likely to be present.
See above. Also, look at history and physical.

7. Given a woman of any age, be able to list the breast cancer screening techniques as recommended by the American Cancer Society.
After age 20 Monthly breast self-examination
20-40 +Physical exam by health professional q3 yrs
40+ +Physical exam by health professional annually + Mammogram annually